Steroid preservation: the rationale for continued prescribing

Tailored immunosuppression according to risk stratification for optimal outcome for both immunological and non-immunological risk factors should be the ultimate objective for every child in whom renal transplantation is planned. Renal allograft survival is dependent on the appropriate use of immunosuppressive therapy to prevent acute rejection and chronic allograft nephropathy. Unfortunately, all immunosuppressive therapies, including corticosteroids, have unwanted side effects, including infections, malignancy, nephrotoxicity, hypertension, hyperlipidaemia and diabetes mellitus. However, the most worrying side effects of corticosteroids for children, adolescents and their parents are growth retardation and the cosmetic effects. Consequently, achieving immunosuppressive regimens without corticosteroids would be preferable. The major concern for paediatric nephrologists in the 21st century is no longer acute rejection, as the incidence appears to be decreasing, but infection, particularly EBV and the development of post-transplant lymphoproliferative disease (PTLD). With modern immunosuppressive agents in transplantation, rejection is being traded for infection. The long-term outcome data of PTLD with steroid-free and monoclonal antibody protocols is as yet unknown.